Quality improvement in our health care system is necessary and is being demanded by patients, payors, and health care providers.
Stroke spans the continuum of health care, from prevention to long-term rehabilitation, and is an ideal model for the development
of quality improvement indicators.

This chapter will serve as a first proposal for key indicators to assess acceptable outcomes of acute stroke care. These indicators
may apply to small groups of patients at one particular institution or to a region that encompasses many institutions. The
indicators are arranged according to the timing of particular events in the course of caring for an acute stroke patient (1,2),
and will cover all four domains of measure: clinical, functional, patient and family satisfaction, and cost.

Availability of expertise for treatment of intracerebral and subarachnoid hemorrhage.

Availability of acute stroke care unit or intensive care unit required for patients with subarachnoid hemorrhage or intracerebral
hemorrhage, and for patients with acute ischemic stroke who have received thrombolytic therapy.

Presence of appropriate protocols for management of blood pressure.

Prophylaxis required to prevent deep vein thrombosis.

Initiation of established protocols and programs for secondary prevention of stroke within 24 hours of hospital admission.

Presence of procedures and diagnostic capability for accurate and complete reporting of treatment complications, including
any intracerebral hemorrhage following initiation of thrombolytic therapy.

Measurement of stroke mortality rate.

Measurement of average length-of-stay for acute stroke patients.

Presence of procedures for prompt recording of data needed to document resource utilization.

Presence of procedures for accurately documenting the costs for acute stroke treatment.

Presence of procedures to record discharge status for acute stroke patients.

Use of a protocol for coordination of patient referral and patient care among centers in a region.

A minimum set of key indicators would be less cumbersome to pursue and would serve to initiate the complex process of quality
improvement. This minimum list should consider patient safety to be of paramount importance, and it should assess large impact
issues and indicators for which reasonably reliable measurement tools exist. This minimum list might include:

1. Adams HP, Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute ischemic stroke. A statement
for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994;25:1901-1914.

2. Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: A supplement to the guidelines
for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing
group of the Stroke Council, American Heart Association. Circulation 1996;94:1167-1174.